I discussed something related to this earlier this year (the algorithmic de-skilling of clinicians) and thought that this short presentation added something extra. It’s not just that AI and machine learning have the potential to create scenarios in which qualified clinical experts become de-skilled over time; they will also impact on our ability to teach and learn those skills in the first place.
We’re used to the idea of a novice working closely with a more experienced clinician, and learning from them through observation and questioning (how closely this maps onto reality is a different story). When the tasks usually performed by more experienced clinicians are outsourced to algorithms, who does the novice learn from?
Will clinical supervision consist of talking undergraduate students through the algorithmic decision-making process? Discussing how probabilistic outputs were determined from limited datasets? How to interpret confidence levels of clinical decision-support systems? When clinical decisions are made by AI-based systems in the real-world of clinical practice, what will we lose in the undergraduate clinical programme, and how do we plan on addressing it?
On Saturday I attended a workshop at Groote Schuur hospital that had the aim of providing “…clinicians with the opportunity to improve their ability to facilitate learning in clinical practice”. Objectives included improving the understanding of theories of learning, methods of enhancing learning and assessment practices and the role of assessment in learning. I was impressed with the number of clinical educators and supervisors (about 40) who gave up their Saturdays to attend. Here are my notes:
Learning in clinical practice
How do I learn? Immersive, pulling in additional material, alternative ideas, I need to see the big picture
How do I learn best? Personal, vested interest, answering a question of relevance, application to a relevant problem, can be associated with different sensory modalities
How did I develop “expertise”? Socially, conversation, discussion, sharing, questioning, choosing to “own” something, pushed out of your comfort zone
How does learning happen? Reducing to basic principles, commitment, dedication
When last did you learn something new?
Students feel lost and disorientated when first arriving on a placement, no matter how much they prepare, they still feel unprepared
Theory is linear, it’s neat and “tight”, whereas practicals are messy and untidy. So, theory doesn’t prepare you for practice, only practice does
Students should be allowed to make mistakes, but when a patients health and well-being are at risk, mistakes are problematic. Students want to be “right” (maybe because we stress how important it is that they get it “right”). Clinical skills labs are useful to address the problem of practising and being allowed to make mistakes. But clinical skills labs are expensive
“Learning” is the process of turning information into knowledge through engagement
Learning is about making meaning
Students struggle with theoretical concepts until they have the opportunity see / feel the concept in the real world e.g. low tone, ataxia
Learning happens by linking new ideas to older, established ideas, which is why our perceptions of the world are highly individual
What do we do to develop student, as well as professional identity. The notion that students are “socialised” into the profession
Once students cross a “threshold”, the learning experience opens up to them
Students sometimes know the words, but not what they mean
Many students have trouble navigating between different professional contexts
Reducing power differentials helps students feel at ease and more comfortable with the idea of sharing ideas / themselves, you “humanise” the interaction
Students often don’t have a framework for self-evaluation i.e. they don’t know what a 3rd year should be able to do relative to a qualified practitioner. Their frame of reference is limited to themselves and a few teachers whose thinking process exists inside a black box
Correct errors gently, create a space of emotional safety, learning doesn’t happen in an emotional / financial / social / personal vacuum (in another workshop that I attended the other day, the presenter mentioned the “kind teacher”, an idea that I’ve been thinking about a lot)
Predicting the future by understanding the past allows us to look back at our practice and make long term plans for patient management
Enhancing learning in clinical situations
Why is the clinical learning situation so unique? Good place to apply theory, real world scenarios, BUT also a place that can inspire levels of fear that are not present in a classroom
We can ask students to assess their fears i.e. what are they afraid of and why. Then create an environment in which they can confront their fears and see the outcomes of their fears realised e.g. take off the cardio leads and hear the alarm go off, but also see that the patient continues breathing
Educational theories and frameworks can give students a structure for thinking, can help guide their thought processes, but do they necessarily need a deep understanding of the theory e.g. social constructivism?
Creating relationships between pathology and “normal” helps students understand dysfunction. However, this does little to help them develop a management protocol i.e. relate dysfunction to intervention
Facilitating ethical reasoning in student clinical practice. The relationship between ethical principles should be analysed in the light of their impact on the patient
In the early stages of their training, students don’t yet have the language to articulate ethical dilemmas
Feedback to students around ethical dilemmas should acknowledge the experience, but not pass judgement on any of the parties involved
Students often don’t emphasise the moral and ethical components of their practice, as they believe that technical ability is what they will be assessed on (which is true)
Assessment isn’t perfect
Use rubrics to prepare students in terms of providing a framework for their learning
Students won’t expose their weaknesses if they believe that they will be judged on them
Students must be able to act on the feedback given, which means that it must be timeous in order to be relevant